Ethical aspects in the care of very low birth weight infants.

Advances in the neonatal intensive care (NIC) of the very low birth weight infant (VLBW) have given rise to important ethical questions. (1) Does every VLBW infant have the right to NIC? (2) Who should decide whether to treat? (3) How should resources be allocated for NIC? To play their part in answering these questions, paediatricians must become familiar with the principles of ethical reasoning. A distinction can be drawn between a human being and a human person on the basis of the possession of certain qualities, in the absence of which non-treatment may be justified. It will usually not be possible to make this distinction prospectively and hence it is not of much practical assistance as a criterion for decision making. Future disability of th infant can also be advanced as a reason for non-treatment, but it is not possible to know whether avoidance of disability makes it in the best interest of the infant to not be treated, and hence probable future disability is not per se an acceptable criterion for non-treatment. Pain and distress, however, is within the comprehension of decision makers and its avoidance may be an acceptable criterion for non-treatment (although in practice rarely a helpful one). The most useful criterion is one based on the ethics of resource allocation. Resources should be allocated in accordance with the ethical principles of justice and full beneficence. Criteria based on prognosis should be established to decide which VLBW infants should share in the finite resources directed to NIC.

Nocturnal enuresis in children.

Thousands of Australian children suffer the unhappiness of waking most mornings in a wet bed--almost all can be helped by a sympathetic doctor. Very few of these children have significant organic or psychological problems and little investigation is indicated. Management includes: sympathy and empathy, cessation of unhelpful practices, and conditioning.

Dihydrofolate reductase deficiency causing megaloblastic anemia in two families.

To determine the cause of severe megaloblastosis detected at birth and at four weeks in two unrelated infants their bone marrow and liver cells were studied. Both patients had abnormal deoxyuridine suppression tests, corrected to normal by 5-formyl tetrahydrofolic acid. Liver-cell homogenate from one patient had a previously undetectable level of dihydrofolate reductase restored to normal by high cation concentration in the assay. Activity of the liver-cell homogenate from the other patient, which was one quarter of the normal level, was restored to only half normal activity by high cation concentration. Dihydrofolic acid reductase deficiency prevents this conversion of folic acid to tetrahydrofolic acid; the enzyme activity appears to differ in each patient. A satisfactory clinical response in both patients followed parenteral therapy with 5-formyl tetrahydrofolic acid. One sibling in each family died of a similar illness. Autosomal recessive inheritance is probable.